During this session, Tatiana Chartomatsidou, Clinical Embryologist at Assisting Nature, explained additional IVF treatment procedures, including Time-lapse, MACS, EmbryoGlue, Assisted Hatching, PICSI, IMSI and its usefulness.
Tatiana started her presentation by defining what an add-on means. It’s any technique that is a variation or done as an add-on from the routine in the IVF cycle. It means that these techniques are not essential for your treatment, and they may include the laboratory clinker or other complementary. They are usually new techniques, and they aim to improve the chances of IVF success.
Time-lapse imaging
Normally, when an embryo is cultured, specific incubators are used where the embryos are placed. At specific time points of the culture, the embryos are taken out of the incubator, so the embryologists can observe them under the microscope. This means that despite it takes only a couple of minutes, the embryo conditions are interrupted. Thanks to time-lapse technology, which has cameras inside, embryologists can monitor the embryos without taking them out. This can help to select the best embryo and select it for embryo transfer and freeze.
MACS (Magnetic-activated cell sorting)
MACS technique can help to identify the apoptotic cells in the sperm using an immunogenetic test. Normally, embryologists select the best sperm based on morphology and motility, but this does not mean it is 100% accurate. Apoptotic cells mean that they are damaged, which means this sperm is not suitable for fertilization. Thanks to this technique, it’s possible to sort out damaged sperm and choose only the ones that have a low fragmentation rate. This way, we can improve the overall quality of the sperm that is going to be used and then the embryo quality and the pregnancy rates. This technique does not have any clinical adverse effects at the obstetric and perinatal levels. It is usually used when there is a severe male factor, when there is high DNA fragmentation index, in cases of repeated miscarriages with unidentified causes, previous failed IVF cycles or poor embryo quality, which is not attributed to the eggs.
IMSI (Intracytoplasmic morphologically selected sperm injection)
It’s a method that allows the intracytoplasmatic sperm injection of morphologically selected sperm. The sperm is seen with high magnification (6000 to 6600), and it allows the embryologists to choose only the healthiest sperm with the best morphology. This method is used when spermatozoa have mitochondrial dysfunction or DNA damage. It helps to identify spermatozoa with a normal nucleus and nuclear content. IMSI can contribute to improving the success rates in patients diagnosed with oligo-asthenoteratozoospermia. According to studies, it has been shown that this particular method can lead to better fertilization rates, better embryo quality and, in consequence, better pregnancy rates. In addition, IMSI is a great technique for couples with unexplained infertility or repeated implantation failures.
IMSI is a morphological selection of spermatozoa. Special lenses are used on the microscope to select only the best sperm. Compared to ICSI, it has a much higher level of magnification as it is 6300 x, while with ICSI, it is at 400x magnification. It allows to detection potential defects in the head or middle piece of spermatozoa. Thanks to this method, it’s possible to select the best sperm and decrease the chances of poor quality sperm, which can lead to implantation failure or higher miscarriage risk and in the end, we can improve the pregnancy rates.
IMSI is usually suggested in cases of teratozoospermia or with a severe High DNA fragmentation index, previous fertilisation failure after ICSI, in couples with a history of poor quality embryos or implantation failures and cases of long-term unexplained infertility.
PICSI (Physiological intracytoplasmic sperm injection)
PICSI is a variant of traditional ICSI. As mentioned before, the embryologist selects the sperm based on its motility and morphology, so this is something that can be subjective. PICSI helps with making the process a bit less objective because special dishes are used which have some drops of synthetic material, very similar to hyaluronic acid.
This acid is usually found at the top of the oocytes. What the embryologists try to do is use a synthetic material that combines only the material’s parameters with it. It can be retained and remain attached to these drops, ruling out any other immature or low-quality sperm. The embryologists can use only the best ones – only the highest quality sperm. This technique aims to make the whole procedure less subjective, and more objective and simple. It can help increase pregnancy rates and decrease abortion rates. It is usually suggested for couples with high DNA fragmentation rates or unexplained fertility. It is also recommended in cases of repeated miscarriages, previous failed IVF cycles or cases with a history of unsuccessful IVF attempts. However, it is not suitable for cases of very low sperm motility or low sperm count.
EmbryoGlue
Embryoglue contains hyaluronan, which acts as a bridge between the embryo and the womb. This solution has an optimal composition with a high concentration of hyaluronan and human albumin, supporting the embryo and facilitating implantation in the womb. One of its characteristics is its similarity to the uterine environment, minimizing embryo drifting and aiding the implantation procedure. Studies have shown that using EmbryoGlue can lead to higher delivery rates and an increased chance of multiple births.
Assisted hatching
Assisted hatching is performed in the lab to help the embryo hatch from the zona pellucida. The zona pellucida is a protective layer surrounding the embryo from the early stages of development until the blastocyst stage. Normally, the blastocyst will hatch from the zona to implant in the uterus. When we perform assisted hatching, we create a small hole in the zona, allowing the embryo to easily escape. This technique has shown an increase in clinical pregnancy rates, although there isn’t a significant difference in delivery rates. It is usually performed in special cases to facilitate the results. Typically, assisted hatching is performed in cases of advanced maternal age and when the embryos have a hardened zona pellucida, making natural hatching more difficult. It is also chosen in cases of previous IVF failures or when the quality of the zona pellucida requires it.
Pre-implantation genetic testing (PGT)
Pre-implantation genetic testing (PGT) is performed to genetically assess embryos, determining which ones are suitable for transfer – the ones that are normal and can lead to a healthy pregnancy and live birth. The testing involves performing a biopsy of the embryo on the fifth day of culture when the embryo reaches the blastocyst stage. A small number of cells are removed for genetic testing, and the embryo is then frozen until the test results are available. It’s important to clarify that the cells that give rise to the embryo itself are not touched during the biopsy. Only trophectoderm cells, which will develop into the placenta, are used for testing. PGT is performed to avoid transferring abnormal embryos, as they can lead to failed implantation, miscarriages, or pregnancies with genetic conditions. By selecting normal embryos, delivery rates can be improved. PGT is usually suggested in cases of advanced maternal age, recurrent IVF failures, couples with a history of recurrent miscarriages, and cases where one or both potential parents have abnormal karyotypes.
There are many techniques available, some of which have been in routine practice for years. However, new techniques are constantly being developed, and we can expect to see more shortly. All of these techniques aim to improve the outcomes of fertility treatments. It’s important to offer these techniques responsibly, taking into account the couple’s history and each case. In IVF, every case is unique, and the focus is always on the couple. Treatment options should be determined based on the suggestions of the physicians to provide the best solution and achieve a successful and healthy live birth, which is the ultimate goal.
